IURC PIPELINE SAFETY ANNUAL REPORT State Form 54952 (R3 / 9-19) INDIANA UTILITY REGULATORY COMMISSION

INDIANA UTILITY REGULATORY COMMISSION PIPELINE SAFETY DIVISION 101 W Washington St, Suite 1500E

Indianapolis, IN 46204-3407 Telephone: (317) 232-2701

Fax: (317) 233-2410 Submit by E-mail: PipeLineInspections@urc.in.gov

Master meter gas operators may use this form to provide their annual state report as required by 170 IAC 5-3-4(e)(3). This report is due March 15th of each year.

The following is our annual report for calendar year:

A. (i) Annual Leak Survey: Date (month, day, year): ___________________

Contractor or employee who performed task: _____________________________________________________________

(ii) Annual Cathodic Protection Survey: Date (month, day, year): ___________________

Contractor or employee who performed task: _____________________________________________________________

(iii) Annual Valve Inspection: Date (month, day, year): ___________________

Contractor or employee who performed task: ____________________________________________________________

B. Leak Report for Distribution System:

(i) Number of unrepaired leaks as of January 1 _______________

(ii) Number of leaks reported during the calendar year _______________

(iii) Number of leaks repaired during the calendar year _______________

(iv) Number of leaks on system as of December 31 _______________

C. Current Contact Information:

Property Name

____________________________________________________________________ _____________________________ Name of property Local telephone number (area code)

____________________________________________________________________________________________________ Address of property (number and street, city, state, and ZIP Code)

Management Company or Officer

___________________________________________________________________ _____________________________ Name of officer Title of officer

___________________________________________________________________ _____________________________ Name of Company, Business, or Organization Telephone number (area code)

_____________________________________________________________________________________________________ Address (number and street, city, state, and ZIP Code)

____________________________________________________________________________________________________ E-mail address

Local Supervisor

___________________________________________________________________ _____________________________ Name of supervisor Title of supervisor

_____________________________________________________________________________________________________ Address (number and street, city, state, and ZIP Code)

___________________________ ____________________________ ________________________________________ Office telephone number (area code) Cellular telephone number (area code) E-mail address

___________________________________________________ Signature